Abstract

Healthcare workers (HCWs) are at high risk of hepatitis B virus
infection (HBI) and so the present study was carried out to assess the knowledge
of HCWs in a tertiary care medical college about HBI and hepatitis B vaccine (HBV).

After obtaining approval from Institutional Ethics Committee and
informed consent from the study participants, HCWs that included teaching
faculty, resident doctors, medical students, nurses, laboratory technicians,
administrative staff and support staff (ward boys, attendants and sweepers) were
administered a validated questionnaire. Descriptive statistics was applied for the
categorical variables and the Chi-square test of association was used to assess
the statistical significance of variables.

A total of 300 HCWs were recruited for the study. Although, the overall
knowledge amongst all the HCWs was found to be 68%, only 35.3%HCWs knew
the transmission risk by needle stick injury (NSI). Similarly, only 40% correctly
knew the precautions to be taken for preventing an NSI and 17% for the steps
to be taken to disinfect a blood splash. Almost 92.7% (278/300) HCWs were
aware about the availability of a vaccine, of which only 41% (1123/300) knew
that vaccine will not work in case the patient is already infected. When asked
about the steps to be taken in case of an NSI in non-vaccinated HCWs, only 54.7%
(164/300) replied about treatment with both immunoglobulin and vaccination.
A total of 160 (53.3%) HCWs were found to be vaccinated. The most common
reason for not taking vaccination included an improper understanding of HBV
and the infection it causes.

To conclude, the study highlights good knowledge about hepatitis
B infection with requirement of more emphasis on the practical aspects of
management in a case of NSI/blood splash and can guide to improve the
vaccination status and knowledge of HBI amongst HCWs.

Introduction

Hepatitis B infection (HBI) is a
blood-borne viral disease affecting
the general population with India being
in its intermediate prevalence zone.
The prevalence of HBI in the general
population varies between 3.1 and
11% 1-3 and nearly a million deaths have
been reported annually due to chronic
liver disease complicating HBI.4

Health care workers (HCWs) have
been identified amongst the ‘high risk’
population for contracting the disease.1
HCWs are exposed to patients with HBI
as well as asymptomatic carriers of the Hepatitis B virus (HBV) and thus are
at higher risk of acquiring the disease.
A report has estimated that HCWs are
at a four times greater risk for HBI
as compared to the general public.5, 6
Interestingly, surgeons, laboratory staff
and staff dealing with hemodialysis
are at a greater risk as compared to
physicians and dentists.6

The most common mode of transmission is via a needle stick injury
(NSI) and through an increased exposure
to blood and body fluids.2,7,8 Prevalence
of HBI amongst HCWs due to NSI has
been reported being between 1 and
31%,the variability being attributed to
differences in the respective diagnostic
methods.5TheWHO has estimated that 3
million NSIs occur every year amongst
HCWs, 66,000 (2.2%) of which result
in the victim developing serological
positivity for HBI.1, 8 The HCWs infected
with Hepatitis B while on duty have
been reported to be 1% from an Indian
study.5

HBI can be prevented by an effective
vaccination schedule which has an
efficacy of upto 95%.9India introduced
the Hepatitis B vaccine for vaccinating
HCWs in 2002, and since then a drastic
reduction in the prevalence of HBI was
observed.10 However, there were no
standard monitoring procedures for
vaccination of HCWs, leading to a poor
coverage in this population.2Further,
the efficacy of Hepatitis B vaccine
was adequate only if three doses were
administered.2Lack of awareness of
HBI along with a poor coverage of
vaccination program are major hurdles
in prevention of the disease amongst
HCWs.2,5,11

The term HCWs in our study includes
not only clinicians, surgeons and
medical students but also laboratory
personnel, administrative staff, support
staff (ward boys, attendants, sweepers).
However, the same is not true for a
large majority of other similar studies
who have focused either on medical
students or nurses only.12-14 Hence, we
initiated the present study to assess
the knowledge of HBI and HBV in a
recently functioning medical college
from India.

Methodology

Study design and ethics

A cross-sectional, questionnairebased
qualitative study was carried
out amongst the health care workers
(HCWs) of a newly started medical
college in Mumbai between May
and September 2016. The study was
initiated after the approval from the
Institutional Ethics Committee and
after obtaining informed consent from
the study participants.

A structured questionnaire was
prepared by the study team - which
included two medical students, a
microbiologist and a gastroenterologistand
was subsequently administered
to the study participants. The
questionnaire (Appendix) wa s
validated for content validity and field validity. Test-retest reliability was
assed using Cohen’s kappa coefficient
(0.8).14 The questionnaire had the
following themes: demographic and
general information of the participants
on gender, employment status,
year of appointment in the present
institute, years of experience at present
institution, overall years of experience
in the hospital set up/medical field;
The second theme was related to
the knowledge and awareness of the
participant in regards to HBIand the
last one was about knowledge about
HBV.

Statistics

Descriptive statistics using
proportions was carried out for all the
variables. Chi-square test was carried
out for association of categorical
variables. With a type 1 error of 5%,
power of 80% and population size of
1000 and an expected prevalence of
50%,12 sample size has been calculated
to be 280, rounded to 300.

Results

Demographics

The validated questionnaire with
reliability coefficient of 0.8(Cohen’s
kappa co-efficient), was administered
to the HCWs. A total of 454 HCWs
gave consent for participation and
the questionnaire was subsequently
provided to them. 66.1% of them
(300/454) returned completely filled
questionnaires.

Of these 300, 16.0% (48/300)
questionnaires were received from
faculty teachers, 13.7% (41/300) were
resident medical doctors (hereby will
be called as residents), 17.3% (52/300)
were first year medical students, 13.0%
(39/300) were nursing staff, 16.7%
(50/300) were laboratory technicians,
12.0% (36/300) were administrative staff
and 11.3% (34/300) were support staff.

Of the 300 HCWs, 42.0% (126/300)
were men, and the rest 58.0% (174/300)
were women with mean (SD) age of 32
(11) years. Amongst the HCWs who
were working, 45.0% (135/300) had
experience of less than one year, 30.3%
(91/300) had experience between one
to five years, and 24.7% (74/300) had
experience of more than five years in
the medical field.

Knowledge about hepatitis B infection

The overall knowledge amongst all
the HCWs was found to be 68.0%. 90.0% of HCWs knew that Hepatitis
B is a virus (Table 1). However, correct
knowledge about its transmission,
risk to HCWs, signs and symptoms,
asymptomatic phase, treatment
modality , infective agents and
preventive measures were found to
be slightly above 60%. Surprisingly,
only 35.3% (106/300) HCWs knew the
chances of HBI transmission by needle
stick injury (NSI) to be 30%. Similarly,
only 39.8% (78/196) correctly knew the
steps to be taken for preventing needle
stick injury and 17.3% (29/168) for
disinfecting a blood splash.

Knowledge about modes of
transmission and clinical features of
HBV

The responses regarding the correct
knowledge about the transmission of
HBV were given correctly by more
than 70% HCWs for all the modes of
transmission, except for blood donation
(44.0%), contaminated food (62.0%)
and contaminated water (62.0%).
HCWs were well acquainted with
infective agents for transmission of HBI
(>60% answered correctly). However,
knowledge about saliva being a mode
of transmission (36.0%, 108/300); urine
not being one (49.7%, 149/300) and
for amniotic fluid being one (59.7%,
179/300) (which may not be known
to some) was low. Knowledge was
found to be better in residents (90.4%)
followed by faculty (89.4%) and lowest
amongst administrative staff (45.6%)
and support staff (37.9%).

Regarding the clinical features of HBI,
most of the questions were answered
correctly (>70.0%). However, symptoms
like diarrhoea (40.0%), breathlessness
(53.3%) and the asymptomatic phase
(41.7%) were poorly known. Nearly
4/5th of the study participants correctly
identified the precautions related to
blood transfusion and using a condom
during sexual intercourse.

Knowledge about Hepatitis B vaccine

Of the total, 92.7% (278/300) HCWs
were aware of the availability of
vaccine, of which only 41% (123/300)
knew that vaccine will not work in
case patient is already infected prior
to vaccination.

Although 64.7% (194/300) HCWs
had knowledge regarding the number
of doses required to constitute a
complete course of vaccination, only
32.3% (97/300) HCWs knew about
the importance of carrying out the subsequent anti-HBs titer test for
checking the efficacy of vaccination.
The HCWs agreed that there is a need
for anti-HBs testing post vaccination
(78.7%, 236/300) but almost the same
number (83.7%) wanted the test to be
done even for the general public, which
is not required.

When asked about the precautions
and actions to be taken following a
needle stick injury (NSI) in anonvaccinated
HCW, only 54.7% (164/300)
replied regarding treatment with both
immunoglobulin and vaccination.
However, when asked if the same
incidence occurred with a prior
vaccinated HCW, only 18.7% (56/300)
replied that there is no need for
treatment in regards to hepatitis B.

When asked about the appropriate
time for taking vaccination, 67.2%
(195/300) responded that the vaccination
can be taken anytime whereas26.9%
(78/300) and 5.9% (175/300) said during
childhood and during adulthood
respectively.

Sub-group analyses of knowledge of
the study participants

Table 2 lists the differences observed
in the proportion of study participants
with correct knowledge on various
aspects of HBI and HBV. As expected,
a statistically significant increase in
proportion of overall knowledge of
HBI was observed with faculty and
resident doctors followed by other
streams of participants. However, the
knowledge of faculty and residents
who are actually been approached for
treatment/guidance in case of an NSI/
blood splash was found to be poor
(almost less than 30%), the same was
nil for support staff and only 2.8% for
administrative staff.

Of the total, only 17.3% HCWs had
got themselves tested for HBI. Only
45.0% (72/160) took the booster dose
and only 21.9% (35/160) had tested for
anti-HBs titer post vaccination. 40.0%
(64/160) were vaccinated ‘on the job’
whereas 33.1% (53/160) during college.
20% said that they were vaccinated
during their childhood while 6.3%
(10/160) were unaware when they were
vaccinated.43.7% (131/160) took the
complete course of vaccination while
7.7% (23/160) took less than three doses.

Motivation factors for vaccination

Of the total, 36.3% (109/300) HCWs
responded to the question related to
the motivation factor for vaccination of
which33.9% (37/109) replied that they
took vaccination as they were aware of
HBI while 12.8% (14/109) took due to
job related needs and 11.9% (13/109)
opined that this was a pre-requisite
for their jobs.10.0% (11/109) said
that they had fear of getting infected
or they saw a hepatitis B infected
patient. Guidance of family members
[8.3% (9/109)] and that of a family
doctor[5.5% (6/109)], hospital policy
and teacher’s motivation [3.7% (4/109)]
were also motivational factors.2.8%
(3/109) HCWs took vaccination at their
vaccination program while another
3 took the vaccination on their own.
0.9% (1/109) each was inspired to
take vaccination from reading books,
watching television, under influence
of peers and informed during an
orientation program for MD students.
0.9% (1/109) HCW did not know his/
her motivation factor for vaccination.

Reasons for not taking vaccination

Of the total, 46.7% (140/300) HCWs
provided 174 reasons for not taking
vaccination. The most common reason
was lack of knowledge of the existence
of the vaccine [32.1% (45/140)].Lack
of knowledge of HBI [20% (28/140)]
and lack of knowledge of necessity of
vaccination [28.6% (40/140] were also
common. The other reasons were a lack
of time for vaccination [11.4% (16/140)];
or the conception that the vaccine is
only for children [7.1% (10/140)] or
that the vaccine is too expensive [7.1%
(10/140)].

Training program for creating
awareness about HBI and HBV

Of the total, 6.3% (18/288) HCWs
underwent training related to HBI.
98.3% (283/288) voiced their desire to
participate in such training programs.

Discussion

This study was carried out in response
to the recent decision by the Ministry
of Forest, Environment and Climate
Change (MoFECC), Government of
India of mandatorily monitoring and
administering the complete course of
hepatitis B vaccination to all HCWs.15

The medical college in which the
present study was carried out, started
in 2015. However, the hospital attached
to it was established in 1970. The
hospital started out with only 30 beds,
but presently boasts a bed strength of
636.

It was observed that 33.9% (154/454)
HCWs did not return the questionnaire
and thereby declined to participate
in the study indicating a lack of
knowledge, possibly due to apathy
and/or low level of awareness about
hepatitis B infection in a proportion of
HCWs. Nearly 2/3rd of the participants
had fair knowledge regarding HBI
and 93% were aware of the availability
of HBV but only half of them were
vaccinated.

Greater proportion of patients
with adequate knowledge of HBI was
observed in our study compared to
previous other studies.1,7,16 However,
we observed a poor understanding of
the study participants (particularly
supporter staff ) regarding the
precautions to be taken in case of a NSI
and blood splash. This reiterates the
need for undertaking training sessions
at frequent intervals to sensitize all HCWs for incorporating a safe practice.

It was also found out that nearly 1/4th
of the study participants were lacking
knowledge of the modes of transmission
of HBI which was much lower than the
estimates of other studies17.This could
possibly be due to a misunderstanding
between Hepatitis B virus and other
hepatitis viruses. Additionally, similar
to other studies,18 saliva was not
identified as an infectious sample in
our study.

This study highlights that the
knowledge of women is significantly
higher(p< 0.002) than men which is
similar to the findings of Ghomraoui
et al, 201619 and Thakur Singh e t
al, 2015.20 However, Tatsilong et al,
201616 has shown men to be 3.2 times
more knowledgeable than women,
while Abiola et al, 20167 has shown
no statistically significant difference
between genders. This observation
could also be attributed to more number
of female nurses participation in this
study, who deal with patients with HBI
on a daily basis.

It was also found in the present
study that a significant difference
in knowl e d g e e x i s ted be tween
faculty, residents, support staff and
administrat ive staf f , as was also
observed in other similar studies.16

When compared with the years
of experience in medical field,
surprisingly, the HCWs with less than
or equal to one year of experience
had more knowledge as compared to
other groups. This is contradictory to
the findings of other similar studies,
which show no significant difference
of knowledge between groups with
different years of experience in the
medical field.7,16 This could be attributed
to recently acquired knowledge of the
newly joined HCWs or to better health
education in school/colleges or to a
wider media related awareness.

It was found in this study that
fair knowledge regarding HBV was
prevalent amongst HCWs, unlike
a recent study from Korea among
Family Medicine residents where the
authors have reported an appropriate
knowledge among just 10% of the study
participants.21 Although fair knowledge
of HBV was observed amongst all the
study participants, only 50% of treating
doctors (faculty and residents) knew
about the correct management of NSI
in vaccinated, as well as non-vaccinated HCWs. This is notable, especially
because most of the other cadres have
reported to be relying on doctors to
provide appropriate management of
an NSI.

We also observed a low vaccination
status of HCWs in the present study,
which is similar to the findings of other
similar studies.5,22 The outlined reasons
for not vaccinating were also similar to
other similar studies.19,15

Strengths and limitations of this study

Strengths

The present study gives an in-depth
view of the existing knowledge and
awareness about hepatitis B infection
and the present vaccination status of
the HCWs thereby giving direction
for further planning about training
sessions and vaccination program at
the institute.

The present study used an extensive
validated questionnaire with Cohen’s
kappa co-efficient of 0.8. This study was
carried out in a newly started medical
college. All the employees themselves
filled the questionnaire, thus reducing
the possibility of investigator bias.
The participants were from diverse
occupational classes thus providing
the complete representation a of an
institution.

Limitations

We could not highlight the
reasons for not knowing the steps of
management for NSI/blood splash as
we did not expect such poor knowledge
for the same.
The education level of the
participants was not noted for the
present study.
The sample size was not large
enough for sub-stratification and
post-hoc sub-group analysis.

Conclusion

To conclude, the study highlights
good knowledge about HBI and a
need to emphasize on the practical
aspects of management in case of NSI/
blood splash. This may improve the
vaccination status and knowledge of
HBI amongst HCWs.

Acknowledgements

We are grateful to all the Health
care workers who have willingly
participated in this research.

Funding

We wholeheartedly thank Indian
Council of Medical Research (ICMR) for funding this project under its Short
Term Studentship (STS) program.